Introduction
Trauma Protocols
Initial Assessment and Resuscitation of the Injured Patient
Airway / Cervical Spine Precautions
Breathing
Circulation
Disability
Exposure
Expert Comments
Common Mistakes
Head Injuries
Types of Intracranial Bleeding
Physical Examination
Glasgow Coma Scale
Diagnostic Tests
Specific Management / Measures
Penetrating Injuries of the Neck
Protocol
Blunt Neck Injuries
Chest Injuries
Blunt Chest Injuries
Penetrating Chest Injuries
Common Mistakes
Abdominal Trauma
Blunt Trauma
Penetrating Abdominal Injuries
Splenic Injuries
Liver Injuries
Renal Injuries
Bladder Injuries
Urethral Injuries
Pancreatic Injuries
Rectal Injuries
Common Mistakes
Cricothyroidotomy
Subclavian Vein Catheterization
Internal Jugular Vein Catheterization
Thoracostomy Tube
Scoring Systems in Trauma
Trauma Protocols
3.
4.
5.
6.
7.
Transfusion Flowchart
Apnea Test
1. T4 Protocol
1. C-Spine Evaluation
2. Diagnosed Spinal Cord Injury
8.
9.
10.
Flowchart
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Trauma Protocols
INTRODUCTION
The aim of this booklet is to help residents, medical students,
and nurses involved in trauma care, in the management of the
injured patient, especially during the first few critical hours.
Most topics in trauma are discussed, with special emphasis on
common pitfalls. The clinical protocols in use in the Division of
Trauma and SICU are also included. I am indebted to Aida
Aguilar for preparing the manuscript and overseeing the
printing.
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EXPERT COMMENTS
1. Examination of the trauma patient:
Often this is very difficult because of intoxication, shock or
head injury.
2. Head Injury:
3. Fractures:
4. Common mistakes:
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HEAD INJURIES
These may include injuries of the scalp, skull, brain, and blood
vessels.
Scalp Injuries
1. Laceration of the scalp may be associated with significant
bleeding. Control with deep sutures and compression
dressing. Never send a patient to the radiology suite
before suturing a bleeding scalp wound!
2. Scalp infections may spread intracranially via the emissary
veins.
Skull Injuries
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Brain Injuries
1.
2.
3.
4.
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Intracranial Bleeding
1. Epidural hematoma: Usually due to laceration of the
middle meningial artery or venous sinuses. Commonly
located in the temporal or parietal region, often with
associated fractures. On CT scan it appears as a
hyperdense, biconvex-shape lesion.
2. Subdural hematoma:
a. Acute subdural: It manifests within the first few hours
of injury. It is due to bleeding from injured brain tissue
or from the veins, which bridge the cortex with the
cavernous sinus. On CT scan it appears as a crescentshape, hyperdense lesion.
b. Chronic subdural: It may appear many days, weeks or
months after the injury. More common in elderly
patients. On CT scan it shows as a crescent-shape,
hypodense lesion.
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Best
Verbal (5)
4 Spontaneous
5 Oriented
3 To Voice
4 Confused
2 To Pain
3 Inappropriate
1 No Response
2 Incomprehensible
1 No Response
(back to physiologic scoring systems)
Best
Motor (6)
6 Follows
Commands
5 Localize to
Pain
4 Withdraw to
Pain
3 Decorticate
2 Decerebrate
Diagnostic tests
1. Plain skull x-rays only if CT scan is not available (may show
fractures, foreign bodies, air in the skull, shifting of
calcified midline structures). A linear fracture increases
the risk of intracranial hematoma by 400 times.
2. Cervical spine x-rays and CT scan for all unconscious
patients and those with suspicious symptoms (local
tenderness, neurological signs).
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Specific Management
1. All patients with skull fractures, history of loss of
consciousness, seizures, significant headache, amnesia,
depressed level of consciousness, and focal deficits should
be admitted. If in doubt, e.g. when dealing with infants or
drunken patients, admit.
2. Closed, uncomplicated fractures: Symptomatic
management, observation for 2-3 days; no need for
antibiotics.
3. Compound fractures, uncomplicated: Observation for 2-3
days, single dose of antibiotic prophylaxis, washout and
closure.
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Specific Measures
a. CSF drainage through an intraventricular catheter.
b. Mannitol 0.5-1.0 g/Kg over 20 minutes (keep serum
osmolality <320 m 0sm/L) provided that the patient is
hemodynamically stable. Hypertonic saline (250 mls 3%)
is an excellent alternative.
c. Lower pCO2 to 32-35 mmHg by means of
hyperventilation (hypocapnia causes constriction of the
cerebral vessels, thus decreasing the ICP). Avoid
excessive hypocapnia (PCO2 <32), because severe
vasoconstriction may result in brain hypoxia.
d. Barbiturates for persistent intracranial hypertension.
e. Always try to keep CPP > 70 mm Hg (>50 mmHg in young
children).
The following therapeutic modalities are reserved for
refractory intracranial hypertension: Barbiturate coma,
hypothermia, hypertensive CPP treatment, and
craniectomy.
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Common Mistakes
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3.
4.
5.
6.
7.
E. NONOPERATIVE MANAGEMENT
Patients selected for nonoperative management are admitted
for observation, and frequent clinical reassessments. If the
patient develops signs suggestive of a serious neck injury, an
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Common mistakes
hematoma, without a
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CHEST INJURIES
PRINCIPLES OF MANAGEMENT
Always start with ABCs.
During the Primary Survey, the following life-threatening
conditions from the chest should be identified and treated:
1)
Tension pneumothorax
2)
Fail chest
3)
4)
Massive hemothorax
5)
Cardiac tamponade
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1)
2)
3)
4)
5)
Myocardial contusion
6)
Pulmonary contusion
BLUNT TRAUMA
A. RIB FRACTURES
Diagnosis
1. Clinical history: Pain aggravated by breathing or coughing.
2. Anteroposterior compression of the chest elicits pain.
3. Radiological (Fractures at the costochondral junction may
not be seen on the x-rays.)
Treatment
1. Mild to moderate pain: oral analgesics.
2. Severe pain: Consider epidural or patient-controlled
analgesia.
3. Multiple fractures in an elderly patient: admission to SICU
and epidural anesthesia.
Associated Injuries to be excluded
1. Hemopneumothorax.
2. Fractures of the first three ribs may be associated with
injuries of the subclavian vessels or major bronchi.
3. Lung contusion.
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5. Aortic rupture.
6. Diaphragmatic rupture.
7. Fractures of the lower ribs often associated with injuries of
the spleen, liver or kidney.
B. FLAIL CHEST (See illustration)
Cause
Adjacent ribs.
Investigations
1. X-rays. (See X-Ray)
2. Pulse oximetry and serial blood gases in multiple fractures.
The initial blood gases may be normal!
3. Chest CT scan in severe chest trauma to assess the degree
of lung contusion and evaluate for other associated
injuries (i.e. aortic rupture).
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Treatment
1. Continuous monitoring of SaO2 and blood gases in
multiple fractures.
2. Normal SaO2 and blood gases: Analgesia (consider
epidural or patient-controlled analgesia).
3. Respiratory failure or flail chest: Mechanical ventilation.
4. Low threshold for mechanical ventilation in severe
multitrauma or elderly patients.
C. PNEUMOTHORAX
Definition: The presence of free air in the pleural cavity.
Symptoms and signs
1. Often asymptomatic.
2. Dyspnea, tachypnea.
3. Diminished breath sounds, hyperresonance, poorly moving
hemithorax.
Investigations
Chest x-ray, preferably erect and in expiration.
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Treatment
1. Small stable pneumothoraces (less than 20%) can be
managed without drainage. Serial x-rays for reassessment
are recommended. This approach does not apply to
patients scheduled for general anesthesia or assisted
ventilation or air transport because of the danger of
developing a tension pneumothorax. In rare occasions,
even these patients can safely be managed without a chest
tube insertion, provided the patient is closely monitored.
2. Significant pneumothoraces require a chest drain. The
th
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Investigations
The diagnosis is clinical. No time for x-rays!
Treatment
1. Insert a needle into the pleural cavity through the anterior
3rd or 4th intercostal space, midclavicular line or at the 5th
intercostal space midaxillary line to release the tension.
2. Insert a chest tube at the usual midaxillary line.
PERSISTING ATELECTASIS AFTER CHEST DRAIN INSERTION
1. Incentive spirometry, deep breathing, coughing.
2. Consider therapeutic bronchoscopy.
SUBCUTANEOUS EMPHYSEMA
Definition: Presence of air in the subcutaneous tissues.
Possible causes:
1. Pneumothorax associated with torn pleura and intercostal
muscles.
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Treatment
1. Resuscitation as necessary. Keep a slightly low systolic
pressure (about 90 mmHg) with beta blockers
2. Surgical repair or endovascular stent/graft.
3. Non-operative management for minor aortic injuries in
severe multitrauma or elderly patients.
J. DIAPHRAGMATIC INJURIES
In blunt trauma the diaphragmatic rupture is usually due to
severe abdominal trauma which results in a sudden, major
increase of the intra-abdominal pressure. The tear is usually
7-10 cm long. Broken ribs can also cause a diaphragmatic
tear. Deceleration injuries may result in avulsion of the
diaphragm from its peripheral attachments. Most of the
injuries involve the left diaphragm (80%). Rupture of the right
diaphragm requires a much more intense force and is almost
always associated with other intra-abdominal injuries. The
diagnosis is discussed in the penetrating trauma section.
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PENETRATING TRAUMA
Hemopneumothorax. As described in Blunt Trauma.
A. PENETRATING INJURIES OF THE HEART (see photo)
Many of the victims die before reaching hospital care. The
natural selection of the survivors depends on many factors:
time from injury to medical care, weapon, site and size of the
cardiac injury, the presence of tamponade, and associated
injuries.
Clinical Presentation
1. Restless patient. (Often mistaken as alcohol or drug
intoxication!)
2. Shock, tachycardia, weak peripheral pulses
3. Signs of cardiac tamponade: Becks triad (shock,
distended neck veins, distant cardiac sounds).
This is present in 90% of patients with tamponade. Pulsus
paradoxus is present in only 10% of the cases.
4. Every penetrating injury to the chest (especially in
hypotensive patients) is a cardiac injury until proven
otherwise. TOC
Investigations
DO NOT waste valuable time on unnecessary procedures if the
diagnosis is obvious. Investigations should be done only if the
diagnosis is uncertain.
1. Trauma ultrasound performed by a surgeon or ER
physician is the best investigation.
2. Chest x-ray: This should be erect and straight whenever
possible. Radiological signs suggestive of cardiac injury:
a. enlarged cardiac shadow
b. pneumopericardium
c. widened upper mediastinum
3. CVP measurements: If the CVP is higher than 12 cm H2O,
suspect tamponade. However, be aware that many
conditions such as hemopneumothorax, restlessness, fluid
overload, mechanical ventilation, and a misplaced catheter
may give a raised CVP. On the other hand, a tamponade
associated with severe hypovolemia may not show a
raised CVP.
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Treatment
1. Insert one or two large-bore intravenous lines, give oxygen
by mask or via endotracheal tube, and transfer to the OR
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Prognosis
B. DIAPHRAGMATIC INJURIES
Have a high index of suspicion for every penetrating injury
in the left lower chest (between nipple and costal margin).
Injuries to the right diaphragm rarely have any clinical
significance, except for anterior injuries. In left
diaphragmatic injuries, the positive intra-abdominal
pressure might cause migration of abdominal viscera into
the chest and formation of diaphragmatic hernia.
Incidence
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C. ESOPHAGEAL INJURIES
High index of suspicion in posterior stab wounds near the
spine and bullet injuries involving the posterior
mediastinum. Mediastinal emphysema is a suspicious
radiological sign. For transmediastinal gunshot wounds, a
multislice CT scan may be very useful by demonstrating the
bullet tract (See Example). If the tract is away from the
esophagus or the aorta, no further investigations are
needed. If the tract is near the esophagus, investigation by
means of a water-soluble contrast (Gastrografin) swallow
should be performed. A negative study should be followed
by thin barium.
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Common Mistakes
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ABDOMINAL TRAUMA
There are significant differences in the assessment,
investigations, and treatment between blunt and penetrating
abdominal trauma.
A. BLUNT TRAUMA
Intra-abdominal injuries may occur by four mechanisms:
1. Crushing of an organ against the spine, pelvis or
the abdominal wall.
2. Deceleration forces.
3. Sudden increase of the intraluminal pressure and
bursting of a hollow viscus.
4. Injury by broken lower ribs.
Clinical Examination
Investigations
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SPLENIC INJURIES
Clinical Diagnosis
Signs of hypovolemia (often the patient is hemodynamically
stable), left upper abdominal pain radiating to the left
shoulder (Kehrs sign).
Special Investigations
1. Chest x-ray: possibly fractures of the left lower ribs,
elevated hemidiaphragm, medial displacement of the
stomach, downward displacement of the splenic
flexure, enlarged splenic outline.
2. Trauma ultrasound (FAST)
3. Positive diagnostic peritoneal aspirate (DPA).
4. Elevated WBC.
5. CT scan with intravenous contrast is the most useful
investigation. Besides the anatomical diagnosis of the
splenic injury it may show evidence of active bleeding
or false aneurysm (blushing).
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Treatment
Complications
1. Hemobilia (blood in the biliary system): This may present
with pain, jaundice, hematemesis, or unexplained anemia.
Some cases resolve spontaneously. Persistent cases may
require angiographic embolization.
CT#2,
CT#3)
Clinical Presentation
1. Suprapubic pain.
2. Hematuria.
3. Inability to pass urine.
4. Abdominal distension.
5. Urine extravasation in the scrotum.
Special Investigations
1. The serum urea is usually elevated.
2. Cystogram (the bladder should be filled and oblique x-rays
should always be obtained). If an abdominal CT scan is
performed, a CT cystogram may replace the standard
cystogram.
Treatment
1. All intraperitoneal ruptures should be repaired surgically.
2. Small extraperitoneal ruptures may be managed
nonoperatively with transurethral catheter drainage for
about 10 days.
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E. URETHRAL INJURIES
Almost exclusively in males. Usually associated with pelvic
fractures; less often with falls resulting in straddle injuries.
Clinical Presentation
1. Blood at the urethral meatus.
2. Inability to pass urine.
3. High Floating prostate on rectal examination.
4. Urine extravasation in the scrotum.
Note: Do not insert Foley catheter before urethrogram
if any of the above is present.
Special Investigations
Urethrogram
Treatment
In suspected urethral injuries avoid transurethral
catheterization. If catheterization is attempted, it should be
performed by the most experienced person. Conservative
management. A suprapubic or transurethral catheter is
inserted and kept in place for about two weeks. Endoscopic
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Investigations
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PELVIC FRACTURES
Commonly Associated Injuries
Investigations
1. Always do a rectal examination!
2. Look for signs of bladder or urethral injuries
3. Urinalysis for hematuria.
4. Cystogram (or CT cystogram) or urethrogram as
indicated.
5. CT scan of the abdomen and pelvis.
Management
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SPINAL INJURIES
Causes
Diagnosis
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2.
Common Mistakes
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MAXILLOFACIAL INJURIES
Airway
Hemorrhage
Profuse nasal bleeding is managed by anterior and posterior
nasal packing. Posterior packing can be achieved by inserting
a size 8 Foleys catheter through the nostril into the
oropharynx, and inflating the balloon with 5-10 ml of saline.
The balloon is then impacted in the posterior nasal vault by
gentle traction. Anterior packing is then carried out using
conventional hemostatic material (i.e. nasal tampons, etc.).
Packs should not be left in place for more than 24-48 hours
because of the danger of infection and meningitis. Persistent
bleeding can be managed by angiographic embolization.
Associated Injuries: In GSWs of the face there is a high
incidence of associated brain and spinal cord injuries.
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Common Mistakes
1. Underestimating the danger of airway obstruction. The
patient may deteriorate very rapidly. Consider early
intubation or surgical airway!
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NERVE INJURIES
TYPES OF INJURIES
Neuropraxia
Functional paralysis of the nerve but no obvious anatomical
injury. The prognosis is excellent. Usually due to blunt
trauma or proximity shock wave injuries in gunshot wounds.
Axonotmesis
Division of the nerve fibers (axons), intact neural sheath.
Usually due to blunt trauma. Regeneration of the nerve fibers
will occur. The prognosis is good.
Neurotmesis
Complete or partial division of the neural sheath and nerve
fibers. Needs surgical repair. Radial nerve repair has excellent
prognosis, medial nerve good and ulnar nerve the worst
prognosis.
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1. Proximal Injury:
a. Motor: The patient cannot make a fist. Inability to flex
the index and middle fingers, while the ring and small
fingers can be flexed (by the part of the flexor
profundus digitorum which is innervated by the ulnar
nerve). This is the "benediction" or "Pope"s" hand.
Loss of abduction, flexion and a position of the thumb.
2.
Distal Injury
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B. INCISING WOUNDS
Primary Repair: Indicated for fresh clean wounds.
Technique
1. Local or general anesthesia.
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Pain
Pressure (swollen, tense compartment).
Paresthesia.
Paralysis.
Pink color (not pale, except in advanced stages!).
Pulse (usually palpable, except in advanced stages!).
Differential Diagnosis
1. Nerve injury.
2. Vascular injury.
Investigations
Intra compartmental pressures in doubtful cases.
Fasciotomy is recommended if the pressure is >30 cm
H2O, or if there is strong clinical suspicion of compartment
syndrome.
Treatment
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Anterior
Lateral
Superficial posterior
Deep posterior
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Decompression
Common Mistakes
misleading! In
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BOMB BLASTS
1. The bomb fragments at close range behave like high
velocity missiles and cause damage by direct laceration
and crushing, shock waves, and temporary cavitation. In
addition to that the blast wave can cause major injuries.
At greater distances they behave as low velocity missiles.
2. Blast wave: Compressed air, in the form of a sphere,
expands rapidly. The pressure near the explosive charge is
extremely high and might cause dismemberment.
Immediately after the positive pressure phase there is a
negative pressure or suction component and subsequently
a dynamic pressure due to the expanding gases which
displace an equal volume of air. This air travels at very
high velocity.
Blast injuries in water are more severe than in air.
Gas-containing organs are susceptible to blast wave
injuries:
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SHOTGUN INJURIES
1. Less than 6 meters: behave like high velocity injuries.
Extensive tissue damage. (See example 1 & example 2)
2. Less than 2 meters: the entire charge penetrates the body.
3. More than 6 meters: low velocity injuries.
4. Sawn-off shotguns are more likely to produce low-velocity
injuries even in close distances.
Treatment
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Common Mistakes
High velocity injuries: There may be significant injuries to
adjacent structures (i.e. vessels, solid organs).
SPECIAL BURNS
ESOPHAGEAL BURNS
Acids cause a coagulation necrosis and the biggest damage
occurs in the stomach. Alkali causes a liquefaction necrosis
and the esophagus suffers the most extensive damage.
Treatment
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BATTERY INGESTION
All batteries contain potassium hydroxide. If an ingested
battery leaks, there is danger of caustic injuries. Mercury
batteries may cause poisoning if they leak.
Management
Observe carefully. If after 24 hours the battery is still in the
stomach, then consider endoscopic or surgical removal.
Similarly, if there is radiological evidence of leak, consider
operation.
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1. Airway:
Infants are nose breathers. Keep nares clear, use
orogastric tube rather than nasogastric tube.
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o Atropine
Paralyze: succinylcholine.
Orotracheal intubation.
Always check the position of the tube with a chest x-ray.
High incidence of right-stem intubation (about 17% of
emergency intubations).
3. Cervical Spine:
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6. Chest Trauma:
Children suffer rib fractures less often than adults. When
present, they indicate severe trauma.
Pulmonary contusions are more common in children than
in adults. Aortic rupture is rare!
7. Abdominal Trauma:
Evaluate as in adults.
Nonoperative management of splenic or liver injuries is
more successful in children than adults.
Liberal insertion of nasogastric tube. Very young children
swallow a lot of air and develop gastric distention. This
Common Mistakes
False sense of security because of hemodynamic
stability; children may lose significant amount of blood
and still maintain a normal pressure by vasoconstriction.
GERIATRIC TRAUMA
GENERAL PROBLEMS
1. Higher mortality and morbidity, longer hospital stay and
more disability than younger patients with similar injuries.
2. Mechanism of injury is often a fall or motor traffic
accident. Exclude myocardial infarction, TIA, seizures,
stroke or hypoglycemia causing the fall or automobile
accident.
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3. Consequences of Aging:
a. Greater tendency toward more severe and multiple
fractures.
b. Decreased immune and wound healing due to multiple
factors, often malnutrition.
c. Decreased ability of the heart to respond to
endogenous or exogenous signals to increase cardiac
output.
d. Decreased pulmonary compliance, vital capacity, P02
and increased residual capacity.
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j.
SPECIAL PROBLEMS
1. Airway: Remember dentures!
2. Breathing: Flail chest may not show easily because of cage
rigidity. Pain control is critical in multiple rib fractures
(epidural anesthesia strongly recommended). Consider
liberal early intubation and mechanical ventilation.
3. Circulation:
4. Disability:
5. Exposure:
Common Mistakes
Underestimate the risks in relatively moderate trauma.
Intensive monitoring is critical. Liberal criteria for
admission to ICU. TOC
TRAUMA IN PREGNANCY
SPECIAL PROBLEMS
1. Blood volume increases by 40-50% in third term. The
injured victim may lose up to 1/3 of her volume without
significant hemodynamic changes.
2. Compression of the inferior vena cava by the enlarged
uterus impairs venous return. Left lateral position or
tilting of the spinal board prevents this problem.
3. Injuries to the lower extremities bleed more than usual
4. Risk of placenta abruptio. Consider the diagnosis in all
pregnant patients with vaginal bleeding or lower
abdominal pain.
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COMMON MISTAKES
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RESUSCITATIVE PROCEDURES
RESUSCITATIVE THORACOTOMY
Indications
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CRICOTHYROIDOTOMY
Indication
Airway obstruction where immediate relief is required, or
inability to intubate a hypoxic patient.
Technique
BACK TO PROTOCOLS
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TRISS METHODOLOGY
TRISS combines the RTS, the ISS, the age of the patient, and
the mechanism of trauma (blunt or penetrating), and gives an
estimate of the probability of survival. It is best done by
feeding the above information into specially designed
computer programs. Its role and value have been challenged
and we believe that it has limited or no role in trauma Quality
Improvement. See Trauma.org for further information
BACK TO PROTOCOLS
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MEDICAL DIRECTION:
The Trauma Team Leader will be the Trauma Surgery
Attending Physician or, if not immediately available, the
Emergency Medicine Attending Physician.
TEAM OPERATIONS:
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TEAM ASSIGNMENTS:
Airway Manager (AM) (PG IV or PG III DEM resident) initially positioned at the head of the gurney, follows
Resuscitator's directions regarding necessary airway
management, If directed, performs endotracheal
intubation with or without rapid sequence paralysis as
indicated. Confirms tube placement and ventilates patient
until relieved by R.T.
Procedure Resident 1 (PREM) (PG III PG II DEM Resident) initially positioned on the patient's left side, follows
directions regarding placement of central venous lines
and/or thoracostomy tubes. TOC
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NON-SURGICAL CONSULTANTS
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Rapid Uncontrolled
Hemorrhagic Shock
HEMORRHAGE CONTROL
(surgical / endovascular)
SEND LABS (type and cross,
aPTT, INR, platelet count)
AUTOTRANSFUSE (shed
pleural
blood)
CONTROL HYPOTHERMA
(Warm fluids & vent gases, remove
wet clothing, dry patient, Bair
Hugger)
EMPIRIC
1. > 6 units of RBC
2. History of Coumadin
6 U type compatible
pre thawed plasma
1 U pheresis platelets
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TARGETED
Abnormal aPTT / INR
Platelets < 50x109/L
Fibrinogen <
100mg/dL
Diffuse Nonsurgical
Bleeding
1
2
3
4
5
6
7
8
CT scan
-CSF leaks
-GCS <15
-Localizing signs
Multi-trauma requiring
CT scan
before operation
(depending on type of
injury, OR availability,
etc.)
operation
CT may precede
-GCS > 13
-LOC
-Severe headache
CT scan
Operation
unstable
Hemodynamically
non-neurosurgical operation
Hemodynamically
stable
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*Apnea test
1. Patient should have ventilator adjusted resulting in normal
pH and PaCO2, with 100% saturation.
2. Preoxygenate for 5-10 minutes with 100% FiO2.
3. Disconnect patient from ventilator and place a catheter
down the length of the endotracheal tube. The catheter
should be connected to 100% O2 at 12-15 liters/minute.
4. Observe the patient for approximate 10 minutes for
respiratory effort.
5. The test is stopped when the ABG PCO2>60mm Hg and
rises 20mm Hg above base line.
6. The test should be terminated early and the patient placed
back on the ventilator if spontaneous respiration is noted,
the O2% Sat<90, and/or the patient becomes
hemodynamically unstable.
BACK TO PROTOCOLS
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Pt. Evaluated in ER
YES
NO
1.
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Common Problems:
1.
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Unevaluable Patient
If the patient is unevaluable (head injury, obtunded,
intoxication, distracting injury):
Obtain a CT scan from occiput to T1
If the CT scan is normal by neuroradiologist, there is no
neurological deficit, and the patient remains
unevaluable, clear cervical spine (if suspicion for injury is
low). Obtain MRI of cervical spine (if suspicion is high
and the patient can be transported safely to MRI)
MANAGEMENT OF DIAGNOSED SPINAL CORD INJURY
1.
2.
Steroid therapy
a.NOT indicated in penetrating trauma
b.
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bullet
knife
other
B. Site of injury:
Wound tract:
anterior neck triangle (anterior to SMS muscle)
towards midline
towards clavicle
cant assess
C. Vascular structures
1. Active bleeding:
none,
2. Hypovolemia:
BP>100,
minor,
3. Hematoma:
none,
moderate,
BP 60-90,
small
severe
BP<60
moderate
large
expanding
pulsatile
normal,
diminished,
absent
Superficial temporal:
normal,
diminished,
Brachial or radial:
normal,
diminished,
absent
No,
Left arm:
(wrist/brachial index)
D. Larynx/trachea, esophagus
1.
yes,
no
2.
yes,
no
3.
Subcutaneous emphysema:
4.
Hoarseness:
yes,
no
none,
minor,
moderate,
severe
5.
6.
Hematemesis:
yes,
yes,
no
no
E. Nervous system
1. GCS:
eye response,
verbal response,
2. Localizing signs:
Pupils:
normal,
Limbs:
normal,
monoparesis,
anisocoria
hemiparesis,
monoplegia,
hemiplegia,
quadriplegia
Cranial nerves:
Facial n:
normal,
abnormal
normal,
normal,
hemiparesis,
monoplegia,
normal,
hemiplegia
quadriplegia
yes,
abnormal
monoparesis,
Brown-Sequard
no
Brachial plexus:
Median n (fist):
normal,
abnormal
normal,
abnormal
normal,
abnormal
normal,
abnormal
abnormal
normal,
Flowchart
abnormal
abnormal
abnormal
normal,
normal,
NECK CHAPTER
BACK TO PROTOCOLS
TOC
Operation
NO
Gunshot Wound
s
Hemoptysis
Hoarseness
Painful Swallowing
Subcutaneous emphysema
Hematemesis
Proximity in obtunded pt
.
angio
NO
NO
CT with Contrast
s
Suspicious Tract
s
YES
NO
YES
Esophagography
Endoscopy
y
Observe
s
Angio / Swallow
s
Observation
Color Flow Doppler optional
Vessels Indeterminate CFD or
Poor Visualization
Observe
BACK TO PROTOCOLS
Angiogram
1. Open Technique
2. Strict antiseptic precautions (scrub, gown, mask, gloves).
3. Local anesthesia (Lidocaine 1%).
4. Site of Insertion: Mid-axillary line, always above the level
of Nipples at 4th intercostal space (Below this level there is
danger of diaphragmatic injury). Small incision, about 1.5
cm. (Please avoid long incisions!)
5. Digital exploration for intrapleural adhesions, in the
appropriate cases (i.e. previous chest trauma or
intrathoracic sepsis). Routine digital exploration is
unnecessary.
6. Catheter size 36 in adult males, 32-36 in adult females, and
in children 10-28 depending on age.
7. Insert the drain into the chest directing it towards the apex
and posteriorly, 8-10 cm.. No need for subcutaneous
tunnel. Make sure that all the drain holes are in the
pleural cavity. Connect to underwater drainage system
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TOC
PERITONITIS
Yes
No
OR
Hemodynamically
Stable
FAST
CXR
Hemodynamically
Unstable
FAST
CXR
(Only if immediately
available)
OR
OR
11b. ALGORITHM FOR THE TRIAGE OF PTS WITH PENETRATING ABDOMINAL TRAUMA, IN
THE ABSENCE OF PERITONITIS
Protocols
TOC
PENETRATING ABDOMINAL TRAUMA
NO PERITONITIS
Hemodynamically
Stable
Hemodynamically
Unstable
Yes
Isolated Abdominal
Injury
Thoracoabdominal or
other extraabdominal
Injuries
No
FAST
CXR
Laparoscopy
GSW
SW
OR
Fast -
Fast +
CT
Suspected Solid
Organ Injury
Isolated Abdominal
Injury
OR
Judgment
Observation
OR
DPA
Further
Evaluation
12a. ALGORITHM FOR THE TRIAGE OF PTS WITH BLUNT ABDOMINAL TRAUMA, IN
CLINICALLY EVALUABLE PATIENTS
Protocols
TOC
BLUNT ABDOMINAL TRAUMA
CLINICALLY EVALUABLE PATIENT
PERITONITIS
NO PERITONITIS
Hemodynamically
Stable
OR
Hemodynamically
Unstable
Fast
Fast
CT
+
Judgment
Observation
Other causes of
hemodynamic
instability
OR
YES
No
DPA
Observation
+
Further Evaluation
Resuscitation
OR
Further
Evaluation
12b. ALGORITHM FOR THE TRIAGE OF PTS WITH BLUNT ABDOMINAL TRAUMA, IN
CLINICALLY UNEVALUABLE PATIENTS
Protocols
TOC
Hemodynamically
Stable
Hemodynamically
Stable
Fast
Fast
Irrespective of FAST
Results
CT Scan
OR
+
Judgment
No
Extraabdominal
Injuries
Extra
Abdominal
Injuries
DPA
Observation
OR
CT
BACK TO PROTOCOLS
TOC
BACK TO PROTOCOLS
TOC
BACK TO PROTOCOLS
TOC
Gross Hematuria
Stable Patient
CT abdomen with
IV contrast, CT
cystogram or
regular cystogram
Microscopic Hematuria
Hemodynamic
Instability
Asymptomatic
Postpone studies
until stable
No Studies
BACK TO PROTOCOLS
TOC
BACK TO PROTOCOLS
TOC
TOC
BACK
Epidural Hematoma
BACK
Chronic Subdural
BACK
BACK
Intracerebral Hemorrhage
BACK
BACK
BACK
BACK
Flail Chest
BACK
Flail Chest
BACK
Tension pneumothorax
BACK
Lung contusion
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
injury
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
Subluxation C4-C5
BACK
Lumbar spine
BACK
dislocation
BACK
BACK
BACK
BACK
BACK
Compartment
pressure measurements
BACK
BACK
BACK
BACK
BACK
BACK
Hollow-point bullet
BACK
BACK
Fragmentation of bullet
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK
BACK TO PROTOCOL
Aortic cross-clamping
BACK
BACK TO PROTOCOL
Cardiac defibrillation
during ER thoracotomy
BACK
BACK TO PROTOCOL
Site of Cricothyrodotomy
BACK
BACK
BACK
6
BACK
BACK
XR - XRAY TECHNICIAN
AM - AIRWAY MANAGEMENT
R - RESUSCITATOR
TL - TEAM LEADER
Thoracostomy collection
system
BACK
ssssssystemsystem
Positive DPA
BACK TO PROTOCOL
URGENT
OPERATION
8. Air bubbling
through wound
7. Compression /
dyspnea
6. Bruit + shock
5. Absent or
diminished
peripheral pulse+
shock
4. Pulsatile
hematoma
3. Expanding
Hematoma
2.Shock not
responding to
resuscitation
1. Severe active
bleeding
ANGIOGRAPHY
N
4. Equivocal
Color Flow
Doppler
Suspicious CT
Scan
3. Widened upper
mediastinum
on CXR
2. Bruit + Normal
Pulse
1. Absent or
diminished
pulses+normal
BP
LARYNGOSCOPY
BRONCHOSCOPY
GASTROGRAPHIN
SWALLOW
2. Hoarseness
1. Minor
Hemoptysis
1. Pain on
swallowing
URGENT
OPERATION
2. Brachial
plexus
1. Facial Nerve
1. GASTROGRAFIN SWALLOW
2. LARYNGOSCOPY
3. ESOPHAGOSCOPY
Emphysema with
wound tract
towards midline
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